Chest pain resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2] Alejandro Lemor, M.D. [3]

Chest Pain Resident Survival Guide Microchapters
Overview
Causes
FIRE
Complete Diagnosis
Cardiac
Non-Cardiac
Treatment
Do's
Don'ts

Overview

Chest pain is define as a discomfort or pain felt anywhere along the front of the body between the neck and the upper abdomen. The main causes of chest pain include diseases of cardiac, pulmonary and gastrointestinal etiology, without underestimating other causes like psychiatric and musculoskeletal conditions. Chest pain is one of the most common complains in the ER[1] and it is extremely important to rule out life-threatening conditions that need to be managed immediately; such as myocardial infarction, aortic dissection, esophageal rupture, pulmonary embolism, and tension pneumothorax. It is important to do a complete description of the chest pain, including the location, intensity, quality, onset, radiation, the alleviating and aggravating factors and the associated symptoms. An EKG is the most important initial test to diagnose or rule out a myocardial infarction. The treatment for chest pain would depend on the etiology

Causes

Life-Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[2][3][4][5]

Boxes in the red signify that an urgent management is needed.

Abbreviations: CAD: Coronary artery disease; DVT: Deep venous thrombosis; ECG: Electrocardiogram; LBBB: Left bundle branch block; STEMI: ST elevation myocardial infarction; NSTEMI: Non-ST elevation myocardial infarction; ICU: Intensive care unit; TEE: Transesophageal echocardiography

 
 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of life-threatening chest pain

❑ Sudden onset
❑ Severe shortness of breath
❑ Unstable patient
❑ Related to physical exertion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify cardinal risk factors of acute coronary syndrome (ACS)

❑ Age > 45 years
Hypertension
Smoking
❑ History of CAD
Diabetes mellitus
❑ Male gender
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient has the following findings suggestive of ACS?[2]

❑ Pain described as a heaviness or crushing sensation
❑ Radiates to the left arm, neck and/or jaw
❑ Associated with:
Diaphoresis
Dyspnea
Nausea or vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immediately order a 12-lead ECG
Order cardiac enzymes: Troponin, CK-MB
 
 
 
 
 
 
Rule out other life-threatening conditions
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the ECG has ST elevation?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

STEMI
❑ Pain described as a heaviness or crushing sensation
❑ Radiates to the left arm, neck and/or jaw
❑ Not alleviated by rest or medications
❑ PR depression is absent


New LBBB
ECG evidence of LBBB

❑ QRS ≥ 120 ms
❑ QS or rS in V1
❑ Monophasic R in I, aVL and V6
❑ Chest pain with same characteristics as STEMI
 
Unstable angina/NSTEMI
❑ Pain described as a heaviness or crushing sensation
❑ Radiates to the left arm, neck and/or jaw
❑ Not alleviated by rest or medications
❑ Pain last > 10 min
 
Pericarditis
❑ Sharp and pleuritic pain that is improved by sitting up and leaning forward
❑ Diffuse, non-specific ST elevation
❑ PR depression
❑ PR elevation in lead aVR
 
Pneumothorax
Dyspnea
Hypoxia
Tracheal deviation towards the unaffected side
Hyperresonance on the affected side
 
Aortic dissection
❑ Acute onset of heart failure
❑ Low pitched early diastolic murmur best heard at the 2nd right intercostal space
❑ Asymmetric blood pressure in the upper extremities
Widened mediastinum on chest X-ray
❑ History of:
Hypertension
Marfan syndrome
 
Pulmonary embolism
❑ Sudden onset of chest pain
❑ Severe dyspnea
❑ History of DVT, surgery, malignancy, immobility
❑ Elevated D-dimer
 
Esophageal rupture

❑ Vomiting
❑ Lower chest pain
❑ Cervical subcutaneous emphysema
❑ Overindulgence in alcohol or food
chest X-ray

pleural effusion
pneumothorax
❑ air in the mediastinum or peritoneum
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer:
Aspirin 162-325 mg
Oxygen (2-4 L/min) if satO2 <90%
Beta blockers (unless contraindicated)
❑ Sublingual nitroglycerin 0.4 mg every 5 min for a total of 3 doses
Do not delay primary angioplasty or fibrinolysis

Click here for the detailed management for STEMI

Click here for the detailed management for NSTEMI
 
 
 
❑ Immediately transfer the patient to ICU
❑ Perform pericardiocentesis

Click here for the detailed management
 
 
❑ Immediately order a TEE to confirm diagnosis
❑ Transfer to a cardio-thoracic unit for surgical management

Click here for the detailed management
 
❑ If the patient is stable, order a CT pulmonary angiography to confirm diagnosis

Click here for the detailed management
 
❑ Immediately start antibiotic therapy to prevent mediastinitis and sepsis
❑ Surgical repair of the perforation

Click here for the detailed management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If none of the above conditions is found, proceed to the complete diagnostic approach below
 
 
 
 

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[2][3][4]

Abbreviations: ABG: Arterial blood gases; CAD: Coronary artery disease; CBC: Complete blood count; COPD: Chronic obstructive pulmonary disease; CXR: Chest X-ray; DVT: Deep venous thrombosis; ECG: Electrocardiogram; GERD: Gastroesophageal reflux disease; HF: Heart failure; JVD: Jugular venous distention; LBBB: Left bundle branch block; LVH: Left ventricular hypertrophy; MI: Myocardial infarction; NSTEMI: Non-ST elevation myocardial infarction; P2: Second heart sound, pulmonary component; PE: Pulmonary embolism; S1: First heart sound; S2: Second heart sound; S3: Third heart sound; SLE: Systemic lupus erythematosus; STEMI: ST elevation myocardial infarction; TB: Tuberculosis; TEE: Transesophageal echocardiography; TTE: Transthoracic echocardiography

 
 
 
 
 
 
Characterize the chest pain

❑ Onset (sudden or gradual)
❑ Location (retrosternal, epigastric, chest wall, diffuse)
❑ Type (sharp, pleuritic, heaviness, colicky)
❑ Radiation (shoulder, neck, back)
❑ Duration
❑ Worsened by (activities, position, drugs)

❑ Alleviated by (activities, position, drugs)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms

Non-specific symptoms
Altered mental status
Shortness of breath
Nausea and vomiting
Dizziness
Syncope
Fatigue
Lethargy

Symptoms suggestive of cardiac etiology
❑ Heaviness or crushing sensation (suggestive of myocardial ischemia)
❑ Radiating to left arm, neck and/or jaw (suggestive of myocardial ischemia)
❑ Interscapular pain (suggestive of aortic dissection)
Epigastric pain (suggestive of inferior MI)
Sweating
Palpitations
❑ Pain associated with exertion
Loss of consciousness

Symptoms suggestive of pulmonary etiology
Pleuritic pain

❑ Sharp or knife-like
❑ Increases with respiratory movements

Dyspnea
Cough
Hemoptysis
❑ Unilateral pain and swelling of lower extremity (suggestive of DVT)
❑ Chills (suggestive of pneumonia)

Symptoms suggestive of gastrointestinal etiology
❑ Burning sensation (suggestive of GERD)
❑ Colic (suggestive of cholelithiasis)
Epigastric pain
❑ Pain is associated with:

❑ Meals (suggestive of GERD or peptic ulcer)
❑ Medication intake (eg: NSAIDs)
Swallowing
❑ Changes in position
❑ Wakening during night (suggestive of GERD)
❑ Relieved by antacids
❑ Not related to exercise
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inquire about past medical history and risk factors

❑ Previous episodes of chest pain
❑ Cardiovascular disease

❑ Previous MI
DVT
Hypertension
❑ Family history of MI or CAD

❑ Recent medical procedures

CVC (suggestive of pneumothorax)
Bronchoscopy (suggestive of pneumothorax)
Pleural biopsy (suggestive of pneumothorax)

❑ Pulmonary disease

❑ Previous PE
COPD
Asthma

Malignancy
❑ Recent viral infection (suggestive of pericarditis)
❑ Recent trauma
❑ Recent surgery (<3 months) (suggestive of PE)
Psychiatric disorders
Alcohol intake
Smoking
Cocaine use
Methamphetamine use
Hyperlipidemia
❑ Rheumatoic disorders

SLE
Rheumatoid arthritis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient

Vitals
Fever (non-specific)
Heart rate

Tachycardia (non-specific)
Bradycardia

Blood pressure

Narrow pulse pressure (suggestive of aortic stenosis)
❑ Asymmetric blood pressure in extremities (suggestive of aortic dissection)

Tachypnea (non-specific)

General appearance
Pale
Diaphoretic
❑ Severe distress

Neck
❑ Elevated jugular venous pulse (suggestive of pericarditis)
Kussmaul sign (suggestive of pericarditis)

Cardiovascular examination
Palpation
❑ Pain on palpation of chest wall (suggestive of costochondritis)
Apical impulse (suggestive of LVH in aortic stenosis)
Pulses
Pulsus parvus et tardus (suggestive of aortic stenosis)
Pulsus paradoxus (suggestive of pericarditis)
Auscultation
❑ Presence of S3 and/or S4
Paradoxical splitting of S2 (suggestive of aortic stenosis)
Muffled heart sounds (suggestive of pericarditis)
Pericardial friction rub (suggestive of pericarditis)
Systolic murmur (suggestive of aortic stenosis or hypertrophic cardiomyopathy)
Diastolic murmur (suggestive of aortic dissection

Respiratory examination
❑ Shift of the trachea from midline (suggestive of tension pneumothorax)
Hyperresonance over the affected side (suggestive of tension pneumothorax)
Auscultation

❑ Absent breath sounds in one hemithorax (suggestive of pneumothorax)
Rales (suggestive of HF or pneumonia)
Wheezing (suggestive of asthma or COPD)
Pleural rub (pleuritis

Abdominal examination
❑ Positive Murphy's sign (suggestive of acute cholecystitis)
❑ Resonant percussion over the liver (suggestive of perforated peptic ulcer)
❑ Tenderness over the epigastrium (suggestive of gastrointestinal etiology) ❑ Rectal examination that shows occult bleeding (peptic ulcer)

Neurological examination
Focal abnormalities (suggestive of stroke due to aortic dissection)

Hemiparesis
Vision loss
Aphasia
Hypertonia

Skin
Unilateral vesicular rash located in one or two adjacent dermatomes (suggestive of herpes zoster)
Jaundice (suggestive of acute cholecystitis)

Xanthoma (suggestive of dyslipidemia)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order labs and tests
EKG (most important initial test)
Cardiac enzymes (Troponin, CK-MB)

In high suspicion of MI, do not delay initial management

CBC
ABG
D-dimer
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order imaging studies
According to the suspected etiology
Chest X-ray
Echocardiography
CT angiography
Upper endoscopy
RUQ ultrasound
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the chest pain has any of the following findings suggestive of cardiac etiology?

❑ Pain described as a heaviness or crushing sensation
❑ Radiates to the left arm, neck and/or jaw
❑ Associated with:
Diaphoresis
Dyspnea
Nausea or vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Click here for the cardiac chest pain approach
 
 
 
 
 
Click here for the non-cardiac chest pain approach
 


Cardiac Chest Pain

Click on each disease shown below to see a detail approach for every cause of chest pain.

 
 
 
 
 
 
 
Does the EKG has ST elevation?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the ST elevation specific to an anatomic area?
 
 
 
 
 
 
 
Does the TTE shows valve or aortic abnormalities?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
NO
 
 
 
YES
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the following:

STEMI
❑ Pain described as a heaviness or crushing sensation
❑ Radiates to the left arm, neck and/or jaw
Dyspnea
❑ Associated with diaphoresis, nausea or vomiting
❑ Not alleviated by rest or medications
CK-MB and Troponin elevation

New LBBB
EKG evidence of LBBB

QRS ≥ 120 ms
❑ QS or rS in V1
❑ Monophasic R in I, aVL and V6

❑ Chest pain with same characteristic as STEMI

Coronary vasospasm

Prinzmetal's angina
PCI-induced coronary vasospasm
Cocaine induced
 
Consider the following:
Pericarditis
❑ Sharp and pleuritic pain that is improved by sitting up and leaning forward
❑ Diffuse, non-specific ST elevation
PR depression
❑ PR elevation in lead aVR
Fever
Cough
Pericardial friction rub
 
 
 
Consider the following:

Aortic stenosis
❑ Systolic ejection murmur with ejection click

❑ Best heard at the upper right sternal border
❑ Bilateral radiation to the carotid arteries

TTE findings of stenosis
❑ Exertional dyspnea
Syncope

Aortic dissection
❑ Acute onset of heart failure
❑ Low pitched early diastolic murmur best heard at the 2nd right ICS
Widened mediastinum on chest X-ray
TEE findings of:

❑ Intimal tear
Aortic regurgitation

❑ History of:

Hypertension
Marfan syndrome
 
Consider the following:
Unstable angina/NSTEMI
❑ Pain described as a heaviness or crushing sensation
❑ Radiates to the left arm, neck and/or jaw
Dyspnea
❑ Associated with diaphoresis, nausea or vomiting
❑ Not alleviated by rest or medications
❑ Elevated cardiac enzymes
❑ Pain last > 10 min

Stable angina
❑ Pain described as a heaviness or crushing sensation
❑ Normal value of cardiac enzymes
❑ Pain usually lasts < 10 min
❑ Provoked by exertion or stress
❑ Improves with rest or nitroglycerin
 


Non-Cardiac Chest Pain

Click on each disease shown below to see a detail approach for every cause of chest pain.

 
 
 
 
 
 
 
 
 
Determine the non-cardiac etiology based on the physical examination and tests findings
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pulmonary
 
 
 
 
Gastrointestinal
 
 
 
Other
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the onset sudden?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the following:

Pulmonary embolism
❑ Sudden chest pain
❑ Severe dyspnea
❑ History of DVT, surgery, malignancy, immobility
❑ Elevated D-dimer
Hypoxia

Pneumothorax
Dyspnea
Hypoxia
Tracheal deviation towards the unaffected side
Hyperresonance on the affected side

Asthma exacerbation
❑ Acute shortness of breath
Wheezing
❑ History of asthma
 
Consider the following:


Pulmonary hypertension
Dyspnea on exertion
❑ Increased P2
JVD
❑ Lower extremity edema
❑ History of gradual onset of shortness of breath

Bacterial pneumonia
Productive cough
Fever
Dyspnea
❑ New infiltrate on the CXR

Pulmonary TB
Cough
Hemoptysis
Night sweats
❑ Weight loss
❑ Cavitary lesion on CXR

Pleurisy
❑ Sharp pain associated with inspiration and expiration
❑ Shallow breathing
❑ Look for underlying cause
 
 
Consider the following:

Pancreatitis
❑ Severe epigastric pain radiating to the back
Nausea and vomiting
❑ Increased levels of amilase or lipase
❑ History of alcohol intake or gallstones

Acute cholecystitis
❑ RUQ pain associated with meals
❑ Radiation to right shoulder
❑ Positive Murphy's sign
Nausea and vomiting
Jaundice

GERD
❑ Burning sensation from the epigastrium towards the throat
❑ After meals
❑ Duration: minutes to hours

Peptic ulcer
Epigastric pain:

❑ Starts 5-15 min after a meal (suggestive of gastric ulcer)
❑ Alleviated by meals (suggestive of duodenal ulcer)

❑ Alleviated by antacids

Esophageal spasm
❑ Intermittent intense substernal pain
❑ Worsen by swallowing
❑ Alleviated by nitroglycerin or CCB
Dysphagia

Mallory-Weiss syndrome
❑ Epigastric ± back pain
❑ History of vomiting
Hematemesis
 
 
 
Consider the following:

Musculoskeletal pain
❑ Localized pain
❑ Pain on palpation of costochondral joints
❑ Exacerbated by chest wall movements
❑ History of Rheumatoid arthritis

Herpes zoster
❑ Burning pain localized in a dermatome
❑ Unilateral vesicular rash
❑ History of immunodepresion or severe stress

Psychiatric conditions
Anxiety
Hypochondriasis
Panic attack
 

Treatment

The management of chest pain will depend on the underlying cause. Click on each disease shown below to see a detail management for every cause of chest pain.
Abbreviations: STEMI: ST elevation myocardial infarction; NSTEMI: Non-ST elevation myocardial infarction; GERD: Gastroesophageal reflux disease


CARDIAC PULMONARY GASTROINTESTINAL OTHER
STEMI / LBBB
NSTEMI / Unstable angina
Pericarditis
Aortic dissection
Aortic stenosis
Prinzmetal's angina
PCI-induced coronary vasospasm
Cocaine induced coronary vasospasm
Pulmonary embolism
Pneumothorax
Asthma exacerbation
Pneumonia
Pleuritis
Pancreatitis
Acute cholecystitis
GERD
Peptic ulcer
Esophageal spasm
Mallory-Weiss syndrome
❑ Musculoskeletal pain:
Costochondritis
Rheumatoid arthritis
Rib fracture

Herpes zoster
Anxiety
Panic disorder

Do's

Don'ts

References

  1. Bhuiya F, Pitts SR, McCaig LF. Emergency department visits for chest pain and abdominal pain: United States, 1999–2008. NCHS data brief, no 43. Hyattsville, MD: National Center for Health Statistics. 2010. http://www.cdc.gov/nchs/data/databriefs/db43.pdf
  2. 2.0 2.1 2.2 "2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 127 (23): e663–e828. 2013. doi:10.1161/CIR.0b013e31828478ac. ISSN 0009-7322.
  3. 3.0 3.1 Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE; et al. (2012). "2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 60 (7): 645–81. doi:10.1016/j.jacc.2012.06.004. PMID 22809746.
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  5. Torbicki, A.; Perrier, A.; Konstantinides, S.; Agnelli, G.; Galie, N.; Pruszczyk, P.; Bengel, F.; Brady, A. J.B.; Ferreira, D.; Janssens, U.; Klepetko, W.; Mayer, E.; Remy-Jardin, M.; Bassand, J.-P.; Vahanian, A.; Camm, J.; De Caterina, R.; Dean, V.; Dickstein, K.; Filippatos, G.; Funck-Brentano, C.; Hellemans, I.; Kristensen, S. D.; McGregor, K.; Sechtem, U.; Silber, S.; Tendera, M.; Widimsky, P.; Zamorano, J. L.; Zamorano, J.-L.; Andreotti, F.; Ascherman, M.; Athanassopoulos, G.; De Sutter, J.; Fitzmaurice, D.; Forster, T.; Heras, M.; Jondeau, G.; Kjeldsen, K.; Knuuti, J.; Lang, I.; Lenzen, M.; Lopez-Sendon, J.; Nihoyannopoulos, P.; Perez Isla, L.; Schwehr, U.; Torraca, L.; Vachiery, J.-L. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". European Heart Journal. 29 (18): 2276–2315. doi:10.1093/eurheartj/ehn310. ISSN 0195-668X.
  6. 6.0 6.1 McCord, J.; Jneid, H.; Hollander, J. E.; de Lemos, J. A.; Cercek, B.; Hsue, P.; Gibler, W. B.; Ohman, E. M.; Drew, B.; Philippides, G.; Newby, L. K. (2008). "Management of Cocaine-Associated Chest Pain and Myocardial Infarction: A Scientific Statement From the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology". Circulation. 117 (14): 1897–1907. doi:10.1161/CIRCULATIONAHA.107.188950. ISSN 0009-7322.


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